The Primacy of Non-Maleficence in Medical Ethics

  • Jun 29, 2018
  • By Daniel Moses

By: Dr. Gabriel Andrade, Lecturer of Behavioral Science

With some oversimplification, it could be argued that Medical Ethics is about balancing four main principles, long recognized as central in medical practice throughout the ages: autonomy, beneficence, non-maleficence, and justice. It is commonly agreed that, ever since the beginnings of ethical reflection, non-maleficence has been the most important of these principles, and should be given priority when in conflict with others.


Although Hippocrates did not explicitly mention the phrase “First Do No Harm” in his Oath (the original oath actually states “abstain from doing harm”), it is enshrined in the common medical understanding of ethics. And, indeed, its principle prevails above others.


Take, for example, the case of a person suffering from minor pain who asks her doctor for a massive administration of morphine. When considering the principle of autonomy, it would seem that the right thing to do is to, indeed, comply with the patient’s request. But, inasmuch as morphine is a dangerous substance with great abuse potential, the physician should be aware that the administration of morphine will ultimately cause great harm. In this case, autonomy would be at odds with non-maleficence. The doctor must privilege the latter over the former. First, do no harm. Although the patient may desire a specific procedure, the physician is required to think about whether or not that particular procedure will be harmful for the patient. If in conscience the doctor does believe that the procedure will be harmful, then it should not be prescribed, even if the patient asks for it.


Non-maleficence may also be at odds with beneficence. Most doctors have the legitimate desire to do good. But, as the popular saying goes, the road to hell may sometimes be paved with good intentions. Some procedures may appear to be good in the short term, but they may have very prejudicial consequences in the long term (or even in the short term). Again, the prime principle in Medical Ethics is first doing no harm. If by trying to address a health problem out of a concern with beneficence the patient will end up in an even worse condition, then that procedure should not be done. That is why, amongst other things, when it comes to new biotechnologies, most ethicists prescribe a cautionary principle. Inasmuch as, for the most part, we do not have full knowledge of how some of the newer biotechnologies work, it is better to suspend the administration of those biotechnologies until further knowledge about their workings is gathered. Even if those biotechnologies offer good solutions to particular health problems, they may in fact cause even greater harm.


Justice may also clash with non-maleficence, and again, the latter should take precedence. The just allocation of resources in health care may sometimes imply procedures that will ultimately do more harm to patients. Consider, for example, a famous case put forth by philosopher Philippa Foot and ever since widely popularized: “A brilliant transplant surgeon has five patients, each in need of a different organ, each of whom will die without that organ. Unfortunately, there are no organs available to perform any of these five transplant operations. A healthy young traveler, just passing through the city the doctor works in, comes in for a routine checkup. In the course of doing the checkup, the doctor discovers that his organs are compatible with all five of his dying patients. Suppose further that if the young man were to disappear, no-one would suspect the doctor”. Should the doctor remove the organs from the healthy patient in order to distribute them to the dying patients? Of course not. Although it may be a more efficient and even just allocation of resources, it would still be a moral monstrosity to authorize such a transplant. Again, the reasoning is that non-maleficence takes precedence over the other ethical principles.


These principles need to be taken into account for sound medical practice. Although Ethics is only a minor part of the USMLE Step 1, it is a huge component in the medical profession, and for that reason, every doctor should understand how non-maleficence works.